Pharmacology of

Conscious Sedation
Drugs

Wael Galal; M.D.

Anesthesia Consultant
KFH Al-Baha
The Ideal Sedating Agent
The Ideal Sedating Agent
• Predictable onset of • Short duration of action
action

• Lack of cumulative • Patient safety

effects

• Promote rapid recovery • Reversible

• Minimal side-effects • No residual depression

• Residual analgesia • Painless administration

 Classification
Benzodiapezines:
• Benzodiapezin Opioids: • IV
IV Anesthetics:
es: Anesthetics:
–– Midazolam
Midazolam -Fentanyl –
– Ketamine
Thiopentone
– (Dormicum)
Diazepam -Morphine – Propofol
(Pentohal)
– Diazepam -Meperidine
– Ketamine
(Valium) (Demerol)
– Propofol

ALL THOSE 3-GROUPS DRUGS ARE APPROVED FOR

CONSCIOUS SEDATION BUT AT DIFFERENT SERVICE LOCALION LEVELS
 Discussion Questions

Medications approved for conscious

sedation at KFH include the following:

1. Fentanyl, meperidine, midazolam

2. Phenobarbital, morphine, diazepam
3. Pentothal, magnesium sulfate, propofol
4. 1 and 2 only
 Drug Choice for Conscious
Sedation

• This depends on the requirement of:

– Amnesia  Midazolam
– Analgesia  Opiates / Ketamine
– Relaxation  IV anesthetics/Not
Ketamine
– Consciousness  Avoid anesthetics
 ALL SEDATIVES
Can Do the Following:

• Cause Upper Airway Obstruction

• Produce Respiratory Depression

• Blunt Ventilatory Response to

– CO2 (main ventilatory drive) and
– Oxygen.
•How This
Sedation drugsPresentation Goes?
follow two lists (Adult/Pediatric).

• Each Drug has a Dosage instruction to follow,

initial bolus increments  STOP when a
maximum recommended dose is reached.
GENERAL RULES
• Care with age, excretory organ dysfunction and
debilitation   dosage by 1/3-1/2.
• Specific precautions (Mostly patients with
CNS dep., Resp. disorders and CVD).

• REMEMBER: our target is Moderate

Sedation. Dose-to-effect titration is your
tool.

• Sedating agents potentiate the effects of

one another (Synergism).
 THIS SESSION WILL SIMPLIFY & EXPLAIN

The Conscious Sedation Sheets

(Adults/Pediatric)
Distributed to All Wards
Drugs Used for Adult Sedation
DRUG Adult Dose ONSET SPECIAL REVERSAL PRECAUTIONS
CONSIDERATION AGENT CONTRAINDICATIONS
S & SIDE EFFECTS

MIDAZOLAM Initial dose: Onset: 1 ½-5 min. Reduce dose by 1/3 to FLUMAZENIL P- Elderly/debilitated
(Dormicum) 1mg. – 1/2 when used with (Anexate)
elderly/debilitated Peak: 10-15 min. other CNS depressing C- Hypersensitivity, acute
2.5mg. – healthy drugs or in the elderly narrow angle glaucoma
Anxiolytic adult Duration: 60-90 or debilitated.
Sedative Initial dose should min. Manufacturer
S- CNS / Resp. depression
Amnesic not exceed 2.5mgm. recommends not more
- Hypotension
Anti-convulsant Usual max: Metabolized: liver than 1.5 mgm over at
- Agitation
Average adult<60 least two minutes in
- N/V, hiccups
years: Excreted: kidney patients with
5mg. within 30 min. Recovery is dose decreased pulmonary
Elderly adult >60 dependent, usually reserves.
years: 3.5 mg within 1-2 hrs.
30 min.
IV Dose rate: 1mg.
over 1 min. Wait 2
min. after each
increment to fully
evaluate effects.
Maintain level with
25% of initial IV
dose.
DIAZEPAM Initial dose: 2mg. Onset: 1-5min. Administer into large FLUMAZENIL P- Elderly/debilitated
(Valium) Usual Maximum: vein (Anexate)
10-20mg. within 30 Peak: 2 min. C- Hypersensitivity
mins. Inject close to IV site -Narrow angle glaucoma
Sedative Elderly 5-15 mgm. Duration: 15-60 If additives in IV - Psychosis
Anxiolytic over 30 mins. min. solution, flush tubing
Anti-convulsant IV Dose Rate: 2mg. before and after
S- CNS / resp. depression
over 3-5 min. Wait Metabolized: liver administration.
- N/V
5-10 minutes to
- Hypotension
Fentanyl Initial Dose: Onset: 1-2 min. Reduce dose by 1/4 to 1/3 Naloxone P- Elderly/debilitated
25mcg.- when used with other (Narcan) - Bradyarrhythmias
elderly/debilitated Peak: 3-5 min. CNS depressing drugs or - Head injury
Analgesia 25-50 mcg. –healthy adult in the elderly or - Resp. disease
Sedative Duration: 30-60 min. debilitated.
Usual Maximum: Muscle rigidity from high
100-250 mcg. within 30 Metabolized: liver doses may prevent C-Hpersensitivity
min. adequate chest wall
Excreted: kidney expansion and
IV Dose Rate: respirations. This is S- CNS/resp. depression
Administer slowly. Wait reversed with - Hypotension
5 minutes to evaluate neuromuscular blockers - Muscle rigidity
effect. Maintain level but patient must be - Bradycardia
with 25-50% of initial IV artificially ventilated - N/V
dose. - Puritus
-Seizures

Morphine Initial Dose: Onset: 1 min. Reduce dose by 1/3 to 1/2 Naloxone P- Elderly/debilitated
2.5mg.-elderly/debilitated when given with other (Narcan) -Respiratory conditions
5-10 mg. –healthy adult Peak: 15 min. CNS depressing drugs or -- Seizure disorders
in the elderly or -Head injury
Analgesia Usual Maximum: Duration: 2-4 hrs. debilitated
Sedative 10 mg. within 30 min. C- Hypersensitivity
Metabolized: liver - Biliary colic
IV Dose Rate: S- CNS/resp. depression
Administer slowly. Wait Excreted: kidney - Hypotension
5 min. to evaluate effects - N/V
-Dizziness

Pethedine Initial dose: Onset: 1 min. Reduce dose by 1/3 to 1/2 Naloxone P- Elderly/debilitated
25mg.-elderly/debilitated when given with other (Narcan) - SVT
(Demerol) 50mg.-healthy adult Peak: 5-7 min. CNS depressing drugs or - Seizure disorders
in the elderly or - Respiratory conditions
Usual Maximum Duration: 2-4 hr. debilitated.
100mg. within 30 min.
Analgesia
Sedative
Metabolized: liver C- Hypersensitivity
IV Dose Rate: - MAO inhibitors past 14 days
Administer slowly. Wait Excreted: kidney
5 minutes to evaluate
effects S- CNS/resp. depression
- Hypotension
- N/V
Thiopental Initial dose: Onset: 1- 2 min Reduce dose to 1/3 to 1/2 - S- Hypotension, myocardial depression,
(Pentothal) 50 - 100 mg Peak: 4-8 min when given with other CNS and respiratory depression, nausea,
Usual maximum: CNS depressing drugs or vomiting, diarrhea, laryngospasm
3mg/kg Duration of Action: in the elderly or C- Respiratory conditions
General anaesthetic Incremental and 10 - 30 min debilitated. Porphyrias
agent maximum doses are P- Inactive, debilitated, and elderly may
reduced to 1/3- 1/2 in the Metabolized: liver be more susceptible to adverse effects.
elderly. Increased toxicity with other CNS
Excreted: kidney depressants

KETAMINE Initial dose: Onset: 30 sec. IV Antisecretory agent such as - S- Nystagmus,resp. depression,
0.2 - 1.0 mg/kg 3-4 min. IM atropine (.01mgm/kg) or hypersalivation, laryngospasm, non-
(Ketalar) scopalamine given prior purposeful movements, emesis,
Barbituates and Ketamine
Usual maximum: Duration: 5-10 min.  HR,B/P, ICP
should not be injected using
2mg/kg. IV - “Emergence reaction”
General anaesthetic the same syringe.
agent 12-25 min. Not recommended outside - Unpleasant dreams/hallucinations
IM the OR. (most common in females>age 10)

Full Recovery: 30-120 C- Hx CV disease or hypertension

min - Active pulmonary infection or disease
Initial IV dose over 60 - Head injury
sec. - Glaucoma or acute globe injury
(rapid administration - Psychosis
may cause respiratory - Conditions with intracranial
depression) hypertension
- Seizure or CNS disorders
- Hx of airway instability, tracheal
surgery or stenosis

Propofol Initial dose: Onset: 30 sec Reduce dose by 1/3 to 1/2 - S- Respiratory depression,
10 - 20mg incremental Duration of Action: when given with other CNS -  HR,B/P
(Diprivan) depressing drugs or in the
doses every 5 minutes as 10 - 15 min P- Hx CV disease or hypotension
needed elderly or debilitated. - Active pulmonary infection or disease
Restricted to monitored
General anaesthetic Usual Maximum: - Concomitant use with narcotics
ICU/ED patients and/or use
agent 100mg. by anesthesia personnel - Hx of airway instability, tracheal
Anti-emetic surgery or stenosis
Anti-convulsant Give slow IV push to
avoid hypotension.
Drugs Used for Pediatric Sedation
DRUG Pediatric Dose ONSET SPECIAL REVERSAL PRECAUTIONS
CONSIDERATIONS AGENT CONTRAINDICATIONS
& SIDE EFFECTS
MIDAZOLAM No manufacturer Onset: 1 ½-5 min. Reduce dose by 1/3 to FLUMAZENIL P- Debilitated
(Dormicum) published Peak: 10-15 min. 1/2 when used with (Anexate)
recommendations Duration: 60-90 other CNS depressing C- Hypersensitivity, acute
min. drugs or in the narrow angle glaucoma
Anxiolytic Metabolized: debilitated.
Sedative liver Manufacturer S- CNS / Resp. depression
Amnesic Excreted: kidney recommends not more - Hypotension
Anti-convulsant Recovery is dose than 1.5 mgm over at - Agitation
dependent, usually least two minutes in - N/V, hiccups
1-2 hrs. patients with decreased
pulmonary reserves.

DIAZEPAM No manufacturer Onset: 1-5min. Administer into large FLUMAZENIL P- Debilitated

(Valium) published Peak: 2 min. vein (Anexate)
recommendations Duration: 15-60 C- Hypersensitivity
Clinician info: min. Inject close to IV site - Narrow angle glaucoma
Sedative >30 days of age Metabolized: - Psychosis
Anxiolytic 0.25mg/KG over 3 liver If additives in IV
Anti-convulsant min. Can repeat in Excreted: kidney solution, flush tubing
15-30 min. until total before and after S- CNS /resp. depression
of 0.75mg/Kg administration. - N/V
- Hypotension
Never IM -Dizziness
Fentanyl No manufacturer Onset: 1-2 min. Reduce dose by 1/4 to Naloxone P- Debilitated
published 1/3 (Narcan) - Bradyarrhythmias
recommendations Peak: 3-5 min. when used with other - Head injury
CNS depressing drugs - Resp. disease
Analgesia
Duration: 30-60 or in the debilitated.
Sedative
min. Muscle rigidity from
high doses may prevent
C-Hpersensitivity
Metabolized: liver adequate chest wall
expansion and S- CNS/resp. depression
Excreted: kidney respirations. This is - Hypotension
reversed with - Muscle rigidity
neuromuscular blockers - Bradycardia
but patient must be - N/V
artificially ventilated. - Puritus
-Seizures

Morphine 0.05-0.1mg/kg slowly Onset: 1 min. Reduce dose by 1/3 to Naloxone P- Debilitated
1/2 when given with (Narcan) -Respiratory conditions
Peak: 15 min. other CNS depressing -- Seizure disorders
Analgesia drugs or in the -Head injury
Sedative Duration: 2-4 hrs. debilitated. -C- Hypersensitivity
-Biliary colic
Metabolized: liver -S- CNS/resp. depression
- Hypotension
Excreted: kidney - N/V
-Dizziness

Pethedine 1-2 mg/kg slowly Onset: 1 min. Reduce dose by 1/3 to Naloxone P- Debilitated
(Demerol) 1/2 when given with (Narcan) - SVT
Peak: 5-7 min. other CNS depressing - Seizure disorders
drugs or in the - Respiratory conditions
Analgesia Duration: 2-4 hr. debilitated.
C- Hypersensitivity
Sedative - MAO inhibitors past 14 days
Metabolized: liver
S- CNS/resp. depression
Excreted: kidney - Hypotension
- N/V
Thiopental Initial dose: Onset: 1- 2 min Reduce dose to 1/3 to 1/2 - S- Hypotension, myocardial depression,
(Pentothal) 50 - 100 mg Peak: 4-8 min when given with other CNS and respiratory depression, nausea,
Usual maximum: Duration of Action: CNS depressing drugs or vomiting, diarrhea, laryngospasm
3mg/kg 10 - 30 min in the inactive or
General anaesthetic Incremental and Metabolized: liver debilitated. C- Respiratory conditions
agent maximum doses are Excreted: kidney Porphyrias
reduced to 1/3- 1/2 in the Not recommended outside
elderly. the OR.

KETAMINE Initial dose: Onset: Antisecretory agent such as - S- Nystagmus,resp. depression,

0.2 - 1.0 mg/kg 30 sec. IV atropine (.01mgm/kg) or hypersalivation, laryngospasm, non-
(Ketalar) scopalamine given prior
3-4 min. IM purposeful movements, emesis,
Barbituates and Ketamine
Usual maximum:  HR,B/P, ICP
should not be injected using
2mg/kg. Duration: - “Emergence reaction”
General anaesthetic the same syringe.
agent 5-10 min. IV - Unpleasant dreams/hallucinations
12-25 min. IM Not recommended outside (most common in females>age 10)
the OR.
Full Recovery: 30-120 C- Hx CV disease or hypertension
min - Active pulmonary infection or disease
Initial IV dose over 60 - Head injury
sec. - Glaucoma or acute globe injury
(rapid administration - Psychosis
may cause respiratory - Conditions with intracranial
depression) hypertension
- Seizure or CNS disorders
- Hx of airway instability, tracheal
surgery or stenosis

Propofol Initial dose: Onset: 30 sec Reduce dose by 1/3 to 1/2 - S- Respiratory depression,
10 - 20mg incremental when given with other CNS -  HR,B/P
(Diprivan) depressing drugs or in the
doses every 5 minutes as Duration of Action:
inactive or debilitated.
needed 10 - 15 min P- Hx CV disease or hypotension
General anaesthetic - Active pulmonary infection or disease
Restricted to monitored
agent Usual Maximum: - Concomitant use with narcotics
ICU/ED patients and/or use
Anti-emetic 100mg. - Hx of airway instability, tracheal
by anesthesia personnel
Anti-convulsant surgery or stenosis
Give slow IV push to
avoid hypotension.
 Reversal Agents for Drugs used for Adult and Pediatric Sedation

ACTION ADMINISTRATION PEDIATRIC DOSING SPECIAL PRECAUTIONS

& GUIDELINES CONSIDERATIONS CONTRAINDICATIONS
DRUG ONSET (In Adults) SIDE EFFECTS

NALOXONE Reversal of 0.4mg. –2mg. IV 0.01mg/kg every 2-3 min. Can precipitate VT/VF in P - Cardiovascular disease
(Narcan) patients with CV disease
narcotics May repeat as needed in May repeat as needed. or receiving potentially
2-3 min. intervals PRN cardiotoxic drugs. C- Hypersensitivity
If does not produce desired - Narcotic dependency
Onset: 1-2 min. outcome a subsequent dose
of 0.1mg/kg may be
administered. S- N/V, sweating
- Tachycardia, hypertension
Alternate infusion at - Pulmonary edema
0.4mg/hour

FLUMAZENIL Reversal of Initial dose: No manufacturer published Can precipitate seizures in P - Resedation, monitor for
(Anexate) 0.2mgm. IV over 15 sec. recommendations those with seizures resedation, respiratory
benzodiazepine Wait 45 sec, additional controlled by depression for up to 120 min.
induced 0.2mg. doses at one benzodiazepines, with Resedation least likely in low
minute intervals until tricyclic depression dose sedation,
sedation maximum of 4 additional overdose & with high risk (eg < 10mg Versed)
doses have been given. for seizures.

Onset: 1-2 min. Maximum cumulative C- Hypersensitivity

dose is 1.0 mg. - Tricyclic antidepressant
Repeat above in 20 min. if overdose
Peak effect: 6-10 needed - Benzodiazepine dependency
min. No more than 3 mg. in
High Risk people may one hour.
be necessary to S - Visual disturbances,
increase interval diaphoresis, seizures,
between doses to over arrhythmias
one minute.
Adult Sedation
Midazolam (Dormicum):
• A Benzodiazepine.
• Initial Dose: 1 - 2.5 mg (max. 2.5 mg).
• Maximum: 3.5 - 5 mg in 30 min.
• How to administer: Evaluate Your Patient first  insert & secure
IV  Give The Initial Dose Slowly  Wait 2 min to evaluate effects
 Give Incremental Dosing in order to maintain sedation level with
¼ of the initial dose  DO NOT EXCEED MAX DOSE.

• Onset: 1 ½ -5 min - Peak: 10-15 min - Duration: 60-90 min.

• Recovery is dose dependent, usually 1-2 hrs.

Pediatric Sedation Midazolam

• Pediatric Patients Less Than 6 Months

of Age No manufacturer published
recommendations

• Pediatric Patients 6 Months to 5 Years

of Age: 0.05 to 0.1 mg/kg

• Pediatric Patients 6 to 12 Years of Age:

0.025 to 0.05 mg/kg
• Elderly
• Debilitated
• Respiratory Disorders

• CNS / Resp. depression

• Hypotension
• Agitation
• N/V
• Hiccups

• Hypersensitivity
• Acute narrow angle glaucoma
Adult Sedation

Diazepam (Valium):
• A Benzodiazepine.

• Initial Dose: 2 mg (max. 2.5 mg).

• Maximum: 10-20 mg in 30 min (1/2 this dose in the
elderly).
• How to administer: Evaluate Your Patient first  insert
& secure IV  Give The Initial Dose Slowly  Wait 5-
10 min to evaluate effects  Give Incremental Doses in
order to maintain sedation level with ¼ of the initial dose
 DO NOT EXCEED MAX DOSE.

• Onset: 1-5 min - Peak: 20 min - Duration: 15-60 min.

Pediatric Sedation Diazepam

• No manufacturer published
recommendations

• > 1 month of age: 0.25 mg/kg over 3 min;

Can repeat in 15-30 min until total of
0.75mg/kg (MAX DOSE)
• Elderly
• Debilitated
• Respiratory Disorders

• CNS / Resp. depression

• Hypotension
• N/V
• Dizziness

• Hypersensitivity
• Acute narrow angle glaucoma
• Psychosis
 Potency
• Midazolam > Diazepam = 1:4

• Diazepam is a more cumulative drug, it

has a long half life (≈30 hrs). Midazolam
t½ =1-2hrs; less cumulative.
 Discussion Questions

Midazolam (Dormicum) is:

1. Approximately four times as potent as

diazepam, a respiratory depressant
2. Usually given in 0.5 - 2 mg. increments
3. Reversed by flumazenil
4. All of the above
Adult Sedation
Fentanyl:
• A Potent Opioid.

• Initial Dose: 25-50 µg.

• Maximum: 100-250 µg in 30 min.
• How to administer: Evaluate Your Patient first  insert
& secure IV  Give The Initial Dose Slowly  Wait 5
min to evaluate effects  Give Incremental Dosing in
order to maintain sedation level with ¼- ½ of the initial
dose  DO NOT EXCEED MAX DOSE.
• Onset: 1-2 min - Peak: 3-5 min - Duration: 30-60
min.
• Recovery is dose dependent, usually 1 hr.
Pediatric Sedation Fentanyl

• No manufacturer published
recommendations

• We try 0.25-1 µg/kg/dose.

• Elderly
• Debilitated
• Respiratory Disorders
• Bradyarrhythmias
• Head injury

• CNS / Resp. depression

• Hypotension, bradycardia
• N/V, pruritus, seizures
• Muscle rigidity

• Hypersensitivity
Adult Sedation
Morphine:
• An Opioid.
• Initial Dose: 2.5-10 mg.
• Maximum: 10 mg in 30 min.
• How to administer: Evaluate Your Patient first  insert
& secure IV  Give The Initial Dose Slowly  Wait 5
min to evaluate effects  Give Incremental Dosing in
order to maintain sedation level with ¼- ½ of the initial
dose  DO NOT EXCEED MAX DOSE.

• Onset: 1 min - Peak: 15 min - Duration: 2-4 hrs.

Pediatric Sedation Morphine

• 0.05 - 0.1 mg/kg slowly

• Elderly
• Debilitated
• Respiratory Disorders
• Seizure disorders
• Head injury

• CNS / Resp. depression

• Hypotension
• N/V, pruritus
• Dizziness

• Hypersensitivity
• Biliary colic
Adult Sedation
Meperidine, Pethidine (Demerol):
• An Opioid.
• Initial Dose: 25-50 mg.
• Maximum: 100 mg in 30 min.
• How to administer: Evaluate Your Patient first  insert
& secure IV  Give The Initial Dose Slowly  Wait 5
min to evaluate effects  Give Incremental Dosing in
order to maintain sedation level with ⅓ - ½ of the initial
dose  DO NOT EXCEED MAX DOSE.

• Onset: 1 min - Peak: 5-7 min - Duration: 2-4 hrs.

Pediatric Sedation Demerol

• 1 - 2 mg/kg slowly
• Elderly
• Debilitated
• Respiratory Disorders
• Seizure disorders
• SVT

• CNS depression
• Resp. depression

• Hypersensitivity
• MAO inhibitors
• Hypotension
• N/V
 Potency
Fentanyl > Morphine > Pethidine

Fentanyl > Morphine : 100 times

Morphine > Pethidine : 10 times

In equivalent doses ..
0.1 mg/kg Morphine=
1mg/kg Pethidine=1µg/kg Fentanyl
 Discussion Questions
Fentanyl is:

1. Capable of causing chest wall rigidity with

inability to ventilate if administered too rapidly
and in large doses; known to cause
hypotension if administered to a hypovolemic
patient
2. A potent respiratory depressant (100 times as
potent as morphine)
3. Usually administered in 250 — 500 ug.
increments
4. 1 and 2 only
Meperidine (Demerol) is:

1. One-tenth as potent as morphine; may

cause nausea, vomiting, hypotension,
dizziness, and urinary retention
2. The narcotic of choice for sedating a
patient. with a history of depression who
takes MAO inhibitors
3. Usually administered in 50 mg.
increments
4. 1 and 3 only
Special Considerations
Administration of IV anesthetic agents for
conscious sedation is not recommended
outside the ICU & OR

Also, sedative drugs are not

recommended in infants < 6 month of age,
ASA III & IV patients outside the OR &
ICU.
 Discussion Questions

Medications approved for conscious

sedation include the following:

1. Fentanyl, meperidine, midazolam

2. Phenobarbital, morphine, diazepam
3. Pentothal, magnesium sulfate, propofol
4. 1 and 2 only
ONE MORE AGENT TO GO in
Pediatric C.S.

CHLORAL HYDRATE
The Gold Standard of the 50’s for
Immobility, Non-painful Conscious
Sedation
i.e. The Radiology Suite
 Disadvantages
• High failure rate (30%)

• Paradoxical excitement

• CNS depression: when it works it produces one thing

only  Unconsciousness and Sleep

• Irritant to skin and mucous membrane

• Unpleasant taste, N/V

• Hypotension, Resp. depression

 CHLORAL HYDRATE
• Dosage: 30-100 mg/kg PO (better) or PR
(less reliable)

• Maximum: 1.5 – 2 gm

• Give with anti-emetic

Alert: Excessive Sedation!!
 Reversal Agents for Drugs used for Adult and Pediatric Sedation

ACTION ADMINISTRATIO PEDIATRIC DOSING SPECIAL PRECAUTIONS

& N GUIDELINES CONSIDERATIONS CONTRAINDICATIONS
DRUG ONSET (In Adults) SIDE EFFECTS

NALOXONE Reversal of 0.4mg. –2mg. IV 0.01mg/kg every 2-3 min. Can precipitate VT/VF in P - Cardiovascular disease
(Narcan) patients with CV disease
narcotics May repeat as needed in May repeat as needed. or receiving potentially
2-3 min. intervals PRN cardiotoxic drugs. C- Hypersensitivity
If does not produce desired - Narcotic dependency
Onset: 1-2 min. outcome a subsequent dose
of 0.1mg/kg may be
administered. S- N/V, sweating
- Tachycardia, hypertension
Alternate infusion at - Pulmonary edema
0.4mg/hour

FLUMAZENIL Reversal of Initial dose: No manufacturer published Can precipitate seizures in P - Resedation, monitor for
(Anexate) 0.2mg IV over 15 sec. recommendations those with seizures resedation, respiratory
benzodiazepine Wait 45 sec, additional controlled by depression for up to 120 min.
induced 0.2mg. doses at one benzodiazepines, with Resedation least likely in low
minute intervals until tricyclic depression dose sedation,
sedation maximum of 4 overdose & with high risk (eg < 10mg Versed)
additional doses have for seizures.
been given.
Onset: 1-2 min. C- Hypersensitivity
Maximum cumulative - Seizure disorders
dose is 1.0 mg. - Tricyclic antidepressant
Peak effect: 6-10 min. Repeat above in 20 min. overdose
High Risk people may if needed - Benzodiazepine dependency
be necessary to increase No more than 3 mg. in
interval between doses one hour.
to over one minute. S - Visual disturbances,
diaphoresis, seizures,
arrhythmias
 Discussion Questions

Naloxone is the proper reversal agents

for the following drugs, except:

1. Fentanyl
2. Midazolam
3. Meperidine (Demerol)
4. Morphine
The following should be considered when
administering naloxone:

1. The dose may need to be repeated because the

duration of action of naloxone may be shorter
than that of the narcotic being reversed
2. Acute narcotic reversal may cause pain, nausea,
vomiting, hypertension and CHF
3. Desired effects are alertness and adequate
ventilation without discomfort; naloxone should be
titrated to effect in 0.1 mg increments to avoid
serious side effects
4. All of the above
Flumazenil:

1. Is a specific reversal agent for

benzodiazepines?
2. May cause seizures in benzodiazepines
dependent patients
3. Should be titrated in effect in 0.2 mg.
increments
4. All of the above
Any Questions